Bubble Continuous Positive Airway Pressure (bCPAP) is a life-saving treatment for children and newborns suffering from respiratory distress. A typical bCPAP circuit consists of an air source with a blender that adjusts the oxygen concentration, a nasal interface that delivers the gas to the patient, and a pressure-generating water reservoir.
The nasal interface and water reservoir are inexpensive, but all existing blenders are expensive and require either compressed medical air (which is typically unavailable in low-resource settings) or electricity, which can be unreliable in these settings.
In many cases, oxygen is the only pressurized gas available. As a result, some improvised devices will provide the patient with pure oxygen, which is harmful to the eyes, lungs, and brain of neonates. We aimed to develop an ultra-low-cost, high-quality bCPAP system that would overcome these scaling challenges.
Bubble CPAP Guidelines
INTRODUCTION
Continuous positive airway pressure (CPAP) is a non-invasive technique for delivering pressurized heated and humidified air and/or oxygen to a spontaneously breathing patient’s airways. The end expiratory pressure produced by CPAP prevents alveolar collapse, increases end-expiratory lung volumes (EELV), and preserves functional residual capacity (FRC). CPAP is a type of respiratory therapy that is commonly used in newborns who have respiratory distress syndrome or other causes of pulmonary dysfunction that result in a lower FRC.
CPAP is also used to treat prematurity apnea and to help prevent small airway collapse.
EQUIPMENT
In the NCCC, bubble continuous positive airway pressure (BCPAP) is the preferred method of administering CPAP. Nursing, respiratory therapy, and physicians work together to care for and maintain BCPAP, including ensuring appropriate bubbling. The Bubble CPAP system consists of the following components:
* A heated and humidified gas source with flow rates ranging from 6 to 8 L/min * A nasal interface (nasal prongs or mask) that connects the patient to the CPAP circuit and pressure generator
* An expiratory limb connected to the BCPAP probe immersed in a 0.25 percent acetic acid bottle
* A water seal canister in which the expiratory limb of the circuit is immersed to a depth in centimeters equal to the desired CPAP pressure (i.e. 1 cm of depth produces 1 cm of H20 pressure)
* BCPAP is typically maintained at 5-8 cm of H20 pressure.
INITIATING BCPAP
1. All infants born at 30 weeks (i.e., infants 22 to 29 6/7 weeks) should be automatically placed on CPAP at 5 cm H2O beginning in the delivery room or as soon as possible. (Note: For ELBW infants, the ELBW guideline recommends starting at +6.)
a. Do not reduce CPAP pressure below 5 cmH20 or discontinue CPAP therapy during the first 24 hours of therapy.
2. Infants 34 weeks CGA and older who require noninvasive respiratory support should begin CPAP at 5 cm H20.
WEANING FROM BCPAP
When the following clinical criteria are met, the first trial off of CPAP for infants with RDS born at 30 weeks GA (with a corrected gestational age of 34 weeks) should take place:
1. I’ve been on bCPAP for at least 48 hours at 5 cm H2O with FiO2 0.21.
2. A respiratory rate of no more than 60 beats per minute for more than two hours.
3. No significant retractions on physical examination.
4. No more than two apneas with bradycardia or desaturations in the previous 24 hours, all of which must be self-limiting.
5. Maintains oxygen saturations of 90% or higher.
6. Not being treated for PDA or sepsis at the moment.
7. Tolerates at least 15 minutes of CPAP-free time during care periods.
Once all of these criteria have been met, infants should be transitioned from CPAP to room air. In this situation, a nasal cannula (low or high flow) should not be used as a first-line weaning device.
If any of the following criteria are met during a weaning trial off positive pressure, the infant will be deemed unsuccessful:
1. A respiratory rate of more than 60 beats per minute for more than 2 hours.
2. Examined retractions with marks.
3. More than two apnea events in a 24-hour period with bradycardia or desaturation OR any event requiring positive pressure ventilation (PPV).
4. Failure to maintain oxygen saturation levels above 90%.
If an infant fails to meet any of the above criteria, he or she should be put back on bCPAP. After a week has passed and all stability criteria have been met, the infant should undergo another trial.
